In early March, a 43-year-old man in Germany began to hear his neighbors talking about him. Their voices blamed him, a former healthcare worker, for not providing enough medical care to his parents. His parents could die from COVID-19 as a result of his negligence, the voices said. In fact, his neighbors were at risk of dying too—and it was all his fault.
Yet these accusations were not from people who lived nearby, but were voices stemming from the man's own mind. He had been diagnosed with paranoid psychosis in 2011. When he was previously hospitalized, he heard voices then too—voices that similarly made critical judgements about his actions. But his current delusions were new ones, and hyper-focused on the pandemic. The man also believed that he was immune to COVID-19 after having been infected by a Chinese message on WhatsApp.
According to the report his doctors published recently in Psychiatric Research, his case is the first official documentation of COVID-19-related delusions in a psychotic patient, and it reveals the potential of the pandemic to influence the symptoms of psychotic disorders like schizophrenia.
The delusions that psychotic people experience are not meaningless noise; they are heavily influenced by what's going on in the world. Historical events, politics, culture, technology, and yes, pandemics, can all be mirrored in the delusional beliefs of mentally ill people. (In 2009, during the swine flu pandemic, people diagnosed with schizophrenia felt their own risk of infection was higher than healthy controls.)
It's one way in which the current pandemic, even when it eventually comes to an end, will continue to haunt us, especially those with mental health issues. People with psychotic disorders could remain stuck with pandemic delusions even after a vaccine is developed or society is reopened. Recognizing that COVID-19 delusions might be here to stay will be crucial in the treatment of psychotic disorders in the years ahead.
"If you were to present me with a hundred people with psychosis and none of them mentioned COVID-19, I would think that was bizarre,” said Joel Gold, an assistant clinical professor of psychiatry at the Icahn School of Medicine at Mount Sinai “The productions of the minds of people with psychosis have meaning. And we should take it very seriously.”
On Halloween night in 2003, at Bellevue Hospital in New York City, Gold first saw a patient who believed he was living in a version of The Truman Show—the 1998 movie about a man whose whole life has been constructed around him as fodder for a hit television program.
In 2012, Gold and his brother Ian published a paper about this new delusional belief (they called it The Truman Show Delusion) which was cropping up in other patients too. Like Mr. A—a man who said he had known for five years that his life was just like the movie. He flew to New York because he believed that 9/11 never happened and seeing the Twin Towers still standing could prove that news events were staged as part of the television programming. When he was admitted to the psychiatry department, he asked to speak to the “director.”
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The Truman Show Delusion couldn't exist without the film, The Truman Show. The movie didn't cause the psychosis to occur, per se, but its themes influenced the patients' disease and their experience of paranoia and delusion, as the COVID-19 pandemic is doing for the man in Germany.
Throughout history, delusional beliefs have picked up on the culture and history surrounding them—some beliefs have peaked in certain eras, then are rarely seen again. King Charles VI of France, in the 14th century, suffered from a common delusion among the rich and royal: the glass delusion. He thought that his body was made of glass, and vulnerable to breaking. He is said to have wrapped himself in blankets to keep his butt from shattering when he sat down.
After the 1830s, the glass delusion disappeared. Later in the 19th century, when cement started to commonly be used as a building material, cement delusions appeared instead, which led people to think they were made of the material.
In Revolutionary France, the guillotine often headlined in delusions—it doesn’t much any more. In the 1940s, psychotic patients had delusional beliefs that they were controlled by radio waves, whereas today delusions are technologically updated to concern implanted computer chips.
Daniel Freeman, a professor of clinical psychiatry at the University of Oxford, said that in the past, the content of delusions was mostly ignored. “Once it was established that the belief was false, then talking about the delusion was discouraged,” he said. “The content of the delusion was considered largely meaningless, even viewed as ‘empty speech acts’.”
But there’s recently been a transformation in how delusions are viewed. It’s now understood that these beliefs don't appear out of nowhere, and that they're not random, said Clara Humpston, a research fellow at the Institute for Mental Health at the University of Birmingham. Some researchers think that delusions come about from the mind trying to understand physical or mental sensations that are confusing—like hearing voices, seeing things, or having cognitive difficulties.
Humans need to find meaning or explanations for those experiences. A person feels perplexed or confused about what is happening around them, and then “there is a moment of enlightenment,” she said. “They suddenly realize, 'Oh it's because I’m being persecuted or watched.' It takes time to develop a fully systematized delusion and the content is usually based on what gives the person meaning.”
When clinicians spend time listening and talking to people with delusions, it’s clear that those beliefs are linked to their personal experiences, environments, and values, Freeman said. Providers engaging with what their patients believe could impact the experience and treatment of their illness.
"Delusions can be hard to change because they often explain such uniquely personal, and often puzzling, experiences," Freeman said. "But it is possible for delusions to change, when individuals are in the right space to calmly consider alternative views and make new learning themselves from direct experience."
The pandemic is going to trickle into delusional beliefs because it is dominating our lives, and also provoking so many powerful emotions. Just living through it could be exacerbating symptoms for psychologically vulnerable people.
“It is a time of raised anxiety levels,” Freeman said. “Even just going outside can make us anxiously think: What is going on? And what is going to happen? And paranoia feeds off fear. As anxiety goes up, paranoia tends to follow in its wake. We may expect higher levels of paranoia in this crisis.”
Several of Humpston's colleagues have told her that they have seen cases of COVID-related delusions in psychotic patients too, though they haven't published about them yet. Patients believed that they had contracted COVID-19 over the phone, or that the whole pandemic was started intentionally by various governments around the world.
Many aspects of the pandemic just so happen to line up with common themes that have persisted in delusional beliefs for centuries, making it more ripe for delusional appropriation. These themes include that a person has lost agency or ownership over their actions or thoughts, that they’re being influenced by an external force, or that there’s a conspiracy or organization targeting them. These insidious influences are often invisible, like a virus.
Humpston said that while we can’t know for certain, she thinks it’s likely that these COVID-19 delusions aren’t going away any time soon. Freeman agreed that it would be “remarkable” if the coronavirus pandemic did not feature in psychosis in the years to come.
Delusional thoughts, though false, can show the profound ways society has been impacted or changed. The Truman Show Delusion was just that—a delusion. But it also revealed how we now live in a world where our technologies are incredibly capable of surveilling us. “I think that shines a light on some of the ways that society is shifting,” Gold said.
James Tilly Matthews, considered to be one of the first well-documented cases of paranoid schizophrenia in the late 1700s, thought there was a large machine called the Air Loom underground in London. The Air Loom was controlling his thoughts and actions through electromagnetic waves.
Roy Porter, a historian of science, wrote in an essay on Matthews that the Air Loom was an attempt to make sense of the times Matthews was living in: he "reacted to the bewildering chaos of the French Revolutionary drama of death and danger, double-dealing and double-meanings by repotting them all within his own private imaginative scenario." He thought that Matthews' delusions also reflected the mistreatment of asylum patients by cruel doctors. "Every age gets the lunatic it deserves," Porter wrote.
But Gold pointed out that delusional content reflecting the world around it is not necessarily surprising. After all, COVID-19 has enmeshed itself into all of our thoughts and anxious ruminations, psychosis or not. People are going to incorporate COVID-19 into their cognitions and feeling states no matter their psychiatric health. In the years to come, all of us will worry much more about virus transmission, cleanliness, or large group events than we did before.
Healthy people can often think they don’t have a lot in common with psychotic people; schizophrenia is one of the most stigmatized mental illnesses. But while COVID-19 might start showing up in delusional beliefs, it will continue to haunt all of us in different ways. In that sense, we are not so different.
“I do think that someone walking into a psychiatric ER a year from now is going to be talking about COVID,” Gold said. “But you know, we’ll be talking about COVID a year from now too. Just because someone has a diagnosis like schizophrenia doesn’t mean that they don’t live in the same world that we do. This is going to be an active element in all of our lives for years.”
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